Date of Appointment(Required) MM slash DD slash YYYY Name First Last Providing the following information is optional. Date of Birth MM slash DD slash YYYY Providing the following information is optional. Are you aware that our office offers 24 hour eVisit care? Yes No Did you have to wait longer than expected to get a scheduled appointment? Yes No How long did you wait to speak to a scheduling staff member? 0-2 minutes 3-5 minutes 5-7 minutes Longer N/A/ (Scheduled in Office) How would you rate the courtesy of the person who scheduled your appointment? 5 Very Courteous 4 3 2 1 Rude How would you rate the courtesy of the staff at the reception desk? 5 Very Courteous 4 3 2 1 Rude How would you rate the competence of the nurse/medical assistant who helped you? Outstanding Good Adequate Needs Improvement Poor N/A Did you feel that your doctor spent an adequate amount of time with you? Yes No Did your doctor discuss health care goals such as; diet and exercise with you? Yes No N/A Please rate the clarity of the doctor’s explanation of your condition and treatment options: Outstanding Good Adequate Needs Improvement Poor N/A Were your questions answered to your satisfaction? Yes No N/A If you needed a follow up appointment, were you asked to schedule the appointment at check-out? Yes No N/A Would you recommend this facility and its staff to your family and friends? Definitely Probably Not Sure Probably Not Definitely Not Please list any areas in which our service could be improved.Please share any additional comments.